The Other Half of the Fracture Equation: Fall Prevention and - - PDF document

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The Other Half of the Fracture Equation: Fall Prevention and - - PDF document

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7/5/2017 OSTEOPOROSIS NEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE School of Medicine Division of Geriatrics The Other Half of the Fracture Equation: Fall Prevention and Management Anna Chodos, MD, MPH Geriatrics, Zuckerberg San

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The Other Half of the Fracture Equation: Fall Prevention and Management

OSTEOPOROSIS NEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE

Anna Chodos, MD, MPH

Geriatrics, Zuckerberg San Francisco General Hospital

July 21, 2016

School of Medicine Division of Geriatrics

Anna.Chodos@ucsf.edu

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Presenter Disclosure Information

  • No relevant disclosures

Anna Chodos

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Presentation Outline

  • Case presentation
  • Prevalence and Consequences
  • Risk factors
  • Screening and Evaluation
  • Prevention
  • Summary

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Presentation Outline

  • Case presentation
  • Prevalence and Consequences
  • Risk factors
  • Screening and Evaluation
  • Prevention
  • Summary

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Case

  • Mr. S is an 83 year old man with of hypertension,
  • steoporosis, alcohol use disorder and multiple

falls who presents with a fall and L1 compression fracture with fragment retropulsion and need for spinal fusion.

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  • He has had 5 falls in the last year.

Indoor falls are associated with shifts in position and feeling off-balance. These falls are not associated with loss of consciousness, palpitations, dizziness, nausea, vomiting, coughing, sneezing, use of bathroom, squatting, getting up from sitting position, or head-turning . All of these falls are associated with alcohol use, 3-5 drinks

  • daily. He is always able to get up and

may need to use a cane or walker for a few days secondary to pain.

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  • All of the outdoor falls are

preceded by lightheadedness without other symptoms. He experiences lightheadedness about 3 times a week, always associated with being up for a long period of time, usually when

  • walking. If he leans against a

building the lightheadedness passes in 15 seconds or so.

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  • Medications:
  • Amlodipine 5 mgs daily
  • Enalapril 10 mgs twice daily
  • Omeprazole 40 mgs daily
  • CaCO3-vitamin D daily

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Presentation Outline

  • Case presentation
  • Prevalence and Consequences
  • Risk factors
  • Screening and Evaluation
  • Prevention
  • Summary

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Why falls?

The odds of a fracture are 7–9 times higher among community-dwelling postmenopausal women with both a fall and osteoporosis or osteopenia, compared with women having a fall or

  • steoporosis/osteopenia only.

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Geusens P, et al. The relationship among history of falls, osteoporosis, and fractures in postmenopausal women. Arch Phys Med Rehabil. 2002;83(7):903–906.

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Fractures Due to Fall in Older Women

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ALL FRACTURES WRIST PROXIMAL HUMERUS ELBOW HIP PATELLA ANKLE FOOT/TOES PELVIS FACE HAND/FINGER TIBIA/FIBULA RIB 10 20 30 40 50 60 70 80 90

Percent Nevitt et al. 1997

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Prevalence

  • ~1/3 of those over 65 will fall in the next year
  • ~1/2 of those over 80 will fall in the next year
  • In 2010, ~7 million Medicare beneficiaries fell

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NEJM 348:42‐49,2003 Clin Ger Med 18:141‐158,2002 Am J Prev Med 2012;43(1):59–62

Falls are Common

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Clinicoecon Outcomes Res. 2013;5:9-18.

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Self-reported falls in US, ≥ 65 years

  • In the past 3 months, how many times have you

fallen? (16% fell)

  • How many of these falls caused an injury?

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  • MMWR. 2008;57:225-229

1.8 Million with Injury 4 Million

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Consequences

  • 1/3 fallers with injuries reported needing help with

ADLs as result of fall injury

  • 1/2 of these expected to need help with ADLs for at

least six months

  • ~10% result in a major injury (fracture, TBI, serious

soft tissue injury)

  • ~350,000 hip fractures annually

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Adv Data 392; 2007 Fall Injury Episodes Among Noninstitutionalized Older Adults: US, 2001–2003

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65+ Number Going to ED/Getting Hospitalized for Falls is Increasing

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To Emergency Department Hospitalized http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014

0.5 1 1.5 2 2.5 2001 2003 2005 2007 2009 2011 2013

Millions

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Death from Falls 65+

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http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014 Number of Deaths

5000 10000 15000 20000 25000 30000 1999 2001 2003 2005 2007 2009 2011 2013

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Costs – Direct medical costs: 30 billion dollars in 2010 – Indirect and direct est 68B by 2020

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Inj Prev 2006; 12(5): 290-5

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Summary

  • Falls are common among older adults
  • Falls affect patient function and are a

major mechanism of injury.

  • Number and rate of falls is increasing

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Presentation Outline

  • Case presentation
  • Incidence and Consequences
  • Risk factors
  • Screening and Evaluation
  • Prevention
  • Summary

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Independent Risk Factors for Falling Among Community-Living Older Adults Risk factor

  • No. of Studies

Significant RR OR

Previous falls

16 1.9-6.6 1.5-6.7

Balance impairment

15 1.2-2.4 1.8-3.5

Decreased muscle strength

9 2.2-2.6 1.2-1.9

Visual impairment

8 1.5-2.3 1.7-2.3

Meds: >4 or psychoactive

8 1.1-2.4 1.7-2.7

Gait impairment

7 1.2-2.2 2.7

Depression

6 1.5-2.8 1.9-2.9

Dizziness or orthostasis

5 2.0 1.5-3.1

ADL disabilities

5 1.5-6.2 1.7-2.5

Age >80

4 1.1-1.3 1.1

Female

3 2.1-3.9 2.3

Low BMI

3 1.5-1.8 3.1

Urinary Incontinence

3 1.3-1.8

Cognitive impairment

3 2.8 1.9-2.1

Pain

2 1.7

JAMA 2010;303:258

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Osteoporos Int. 2009 Dec; 20(12): 2025–2034.

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Osteoporos Int. 2009 Dec; 20(12): 2025–2034.

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Risk factors for injurious falls

Previous injurious fall increases risk of falling ~ 3X

BMC Geriatr. 2014 Nov 18;14:120

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Trip

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Video Capture

  • 2 Long-term facilities in British Columbia
  • 38 months monitoring of common spaces
  • 227 falls in 130 people
  • Correlation between staff investigation and video

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  • Lancet. 2013 Jan 5;381(9860):47-54

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Incorrect weight shifting 41% (93 of 227) of falls Trip or stumble 21% (48) Hit or bump 11% (25) Loss of support 11% (25) Collapse 11% (24) Slipping 3% (6)

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Other risk factors

  • Hypoxia during sleep

– Men with ≥ 10% of sleep time with SaO2 ≤ 90% had RR of 1.25, CI = 1.04-1.51 for one or more falls RR of 1.43, CI = 1.06-1.92 for two or more falls c/t men with ≤10% of sleep time with SaO2 ≤ 90%

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JAGS 62:1853, 2014.

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Frailty

  • Multiple definitions- all (CHS, SOF, WHI) associated

with falls

  • Women’s Health Initiative (3558 participants)

– Weight loss (≥10lbs or 5% over 1 year) – Exhaustion – Low Physical Activity score

  • Average follow-up of 12 years
  • Women with high frailty scores had elevated risk for

falls and fractures

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J Am Geriatr Soc. 2016 Jun 16.

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Presentation Outline

  • Case presentation
  • Incidence and Consequences
  • Risk factors
  • Screening and Evaluation
  • Prevention
  • Summary

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Screening Guidelines for Fall Prevention

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  • Guideline for the Prevention of Falls in Older Persons

– American Geriatrics Society – British Geriatrics Society – American Academy of Orthopaedic Surgeons

JAGS 49:664–672, 2001, updated 2010

  • Practice Parameter: Assessing patients in a

neurology practice for risk of falls

– American Academy of Neurology

Neurology 2008;70;473-479

  • CDC Stopping Elderly Accidents, Death, and Injuries

– July 2015

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Older person encounters health care provider Single fall in past year? Falls Evaluation 2 or more falls last year Presents with acute fall Difficulty with walking or balance Screen for risk of falling Abnormalities in gait

  • r unsteadiness?

No Yes Yes Yes

Reassess annually

No No

AGS/BGS Guideline

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American Academy of Neurology

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Inquire about falls in the past year AND Review risk factors for falling Neurological: stroke dementia gait/mobility problem parkinsonism peripheral neuropathy assistive device LE sensorimotor loss Neurology 2008;70;473-479 General: (not rated) age >65 vision deficit arthritis, arthralgia depression polypharmacy restricted ADLs

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  • If A or B positive:

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Falls Evaluation

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Fallers unlikely to discuss falls

  • Less than half of Medicare beneficiaries who fell saw a

healthcare provider about falls (women>men).

  • Only a third to a quarter who have fallen, report

discussing fall prevention strategies with a healthcare provider.

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Am J Prev Med 2012;43(1):59–62

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Other screening tests

  • Standing unassisted
  • 325 community

elders, 60 or older

  • Time to stand from

sitting, unaided, without use of arms

  • Unable or >2 sec had

an OR of 3.0

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  • Timed Up and Go
  • Time to stand from

chair, walk 3m, and sit back down

  • Cutoff 12 sec had

sensitivity of 83% and specificity of 93%

Nevitt, JAMA 1989 Wrisley, Phys Ther 2010

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http://www.cdc.gov/injury/STEADI

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Screening

  • Ask about falls in the prior year
  • Observe for gait or balance problems in getting up

from chair

  • Consider using CDC STEADI materials for

screening

  • If yes or problems ==>Falls Evaluation

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Falls Evaluation

  • Falls history and circumstances
  • Assessment of:

– balance and gait – LE strength, sensation, coordination – perceived functional ability and fear relating to falling – visual impairment – cognitive impairment – home hazards – footwear and foot problems

  • Cardiovascular examination including orthostasis
  • Medication review

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NICE Clinical Guideline, 2004 JAMA The patient who falls. 303 (3) 2010

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Medications

  • Benzodiazepines
  • Anti-depressants
  • Anti-psychotics
  • Anti-epileptics
  • Anti-hypertensives*
  • Polypharmacy (14% higher risk for each

med added above 4)

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J Gerontol A Biol Sci Med Sci. 2007;62:1172

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What about SPRINT?

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2-arm, multi-center RCT comparing treating HTN to a target of < SBP 120 mm Hg vs <140 mmHg. Study stopped early due to 25% lower relative risk

  • f major CV events and death, and a 27% lower

relative risk of death from any cause

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SPRINT-SENIOR

  • Enrolled 2636 patients ≥75 years

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Exclusions:

  • Standing SBP <110
  • Excluded patients with dementia
  • JAMA. 2016 Jun 28;315(24):2673-82

Results:

  • Death at ~3 years, 8.1% vs 5.5% NNT ~39
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Adverse events

  • Syncope 3% vs 2.4% (ns)
  • Injurious falls 4.9% vs 5.5% (ns)

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Presentation Outline

  • Case presentation
  • Incidence and Consequences
  • Risk factors
  • Screening and Evaluation
  • Prevention
  • Summary

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Independent Risk Factors for Falling Among Community-Living Older Adults Risk factor

  • No. of Studies

Significant RR OR

Previous falls

16 1.9-6.6 1.5-6.7

Balance impairment

15 1.2-2.4 1.8-3.5

Decreased muscle strength

9 2.2-2.6 1.2-1.9

Visual impairment

8 1.5-2.3 1.7-2.3

Meds: >4 or psychoactive

8 1.1-2.4 1.7-2.7

Gait impairment

7 1.2-2.2 2.7

Depression

6 1.5-2.8 1.9-2.9

Dizziness or orthostasis

5 2.0 1.5-3.1

ADL disabilities

5 1.5-6.2 1.7-2.5

Age >80

4 1.1-1.3 1.1

Female

3 2.1-3.9 2.3

Low BMI

3 1.5-1.8 3.1

Urinary Incontinence

3 1.3-1.8

Cognitive impairment

3 2.8 1.9-2.1

Pain

2 1.7

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Previous falls Age Gender BMI ADL Disabilities

Things you can’t change

Balance Strength Vision Gait Impairment Depression Urinary incontinence Cognitive impairment Dizziness or orthostasis Medications Pain

Things you might change

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Effective Interventions

  • Exercise: ↓ # falls and #fallers and risk for fracture

– Multiple component group exercise – Individually prescribed, multiple component, home-based program – Tai Chi group exercise

Gillespie et al Cochrane 2012

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Effective Interventions

  • Multifactorial risk factor program (↓ #falls)
  • Home hazard assessment & modification

(↓ # falls and #fallers). There is some evidence that OT led interventions are more effective than non-OT led interventions

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Effective Interventions

  • Medications: (↓ # falls) Gradual withdrawal of

psychotropic medication; educational program for 1° care MDs

  • Cardiac pacing for fallers with cardioinhibitory

carotid sinus hypersensitivity (↓ #falls)

  • Expedited cataract surgery for first eye(↓ #falls)

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Gillespie et al Cochrane 2012

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Interventions that are Ineffective

  • Vitamin D with or without calcium in those with

adequate Vitamin D levels (? with low levels)

  • Home hazard modification in those without fall

history

  • Hormone replacement therapy
  • Correction of visual deficiency (alone
  • Patient education or cognitive behavioral training

Gillespie et al Cochrane 2012

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What about Vitamin D supplementation?

  • IOM 2009 “Supplemental vitamin D in a dose of 700-

1000 IU a day reduced the risk of falling among older individuals by 19%...”

  • IOM 2011 “…no significant reduction in fall risk related

to vitamin D intake or achieved level in blood.”

  • USPSTF 2012 recommends exercise or physical

therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls.

  • AGS 2013 “Clinicians are strongly advised to

recommend vitamin D supplementation of at least 1,000 international units (IU)/d, …to reduce the risk of fractures and falls.”

  • BMJ 2014 “In pooled analyses, supplementation with

vitamin D, with or without calcium, does not reduce falls by 15% or more.”

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What I Recommend

  • Offer cholecalciferol to all older adults at risk for

falls.

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What about perturbation-based training?

  • RCT 212 patients
  • 24 slip session vs 1 slip session
  • Self-reported falls in the year after the intervention:

– 25% in control vs 13% in intervention

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J Gerontol A Biol Sci Med Sci (2014) 69 (12): 1586-1594

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Perturbation-based training

  • 8 RCTs
  • 404 participants
  • Fewer fallers 29%
  • Fewer falls 46% reduction

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Phys Ther. 2015 May;95(5):700-9

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Presentation Outline

  • Case presentation
  • Incidence and Consequences
  • Risk factors
  • Screening and Evaluation
  • Prevention
  • Summary

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Case

1) Counseled patient regarding alcohol use cessation/reduction and offered naltrexone. 2) In-house evaluation for safety 3) PT/OT evaluation and treatment both in-house and in nursing facility 4) Held all anti-hypertensive agents 5) Continue vitamin D at 1000 int units daily

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Presentation Outline

  • Case presentation
  • Incidence and Consequences
  • Risk factors
  • Screening
  • Prevention and management
  • Summary

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  • Falls are common in older adults.
  • Falls cause significant ADL deficits and most

fractures and in older adults.

  • Falls can be prevented.
  • Ask older adults about falls in the last year and
  • bserve gait and balance.
  • Refer patients at risk for future falls to effective fall

prevention approaches.

Falls-Summary

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What Questions Do You Have?

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http://www.gpscbc.ca/system/files/HandOut%201_Home%20Exercise%20Program_ Final-June02.pdf